1. Some thoughts on multi-morbidity and complex patient populations
Ross E.G. Upshur BA(Hons.)MA,MD,MSc,CCFP,FRCPC
Head, Division of Clinical Public Health, Dalla Lana School of Public Health
Scientific Director, Bridgepoint Collaboratory for Research and Innovation
Assistant Director, Lunenfeld Tanenbaum Research Institute, Sinai Health System
Professor, Department of Family and Community Medicine and DLSPH
University of Toronto

4. Babylon
Next in ingenuity to the marriage custom is their treatment of disease. They have no doctors, but bring their invalids out into the street, where anyone who comes along offers the sufferer advice on his complaint, either from personal experience or observation of a similar complaint in others…Nobody is allowed to pass a sick person in silence; but everyone must ask him what is the matter.

5. The Challenge

6. Chronic Health Conditions Denton and Spencer 2010 Canadian Journal on Aging

7. Schaink et al.

8. Patient Complexity System Complexity Specialty Care Mental Health,
Addiction,
Cognition
Social Determinants of Health
Specialty Care
LTC
Mental Health
Social Services
Primary Care
Acute Care
CCAC
Complex Continuing Care
/Rehab
Emergency Department
Multiple Concurrent Complex Conditions ± Aging

9. Alignment of Treatment Goals
Providers
Patients
Treatment Goals Aligned
Caregivers

11. Interprofessional Model of Practice for Aging and Complex Treatments
IMPACT PLUS: a comprehensive model of
Assessment
Care Planning
Mentorship and training
Interprofessional problem solving model
Includes PCPs, CCAC worker, pharmacist, RNs, NPs, social workers, physiotherapist, OT, dieticians, trainees
PLUS
Psychiatrist & General Internist
IMPACT Plus has 3 special features and 3 components that I want to stress.
An assesment tool
A care planning tool
Mentorship and training tool
Three Components:
Simultaneous interprofessional consult
Includes Psychiatrist
Includes internist

12. Lessons learned Patients : Family caregivers:
feel cared for and heard, given time to actually surface what is important
Co-develop care plans that focus on what is achievable given very diverse and complicated treatment burdens
Family caregivers:
feel supported
able to give voice to their stress
feel empowered to continue to deal with difficult and complex situations

13. Lessons learned Health Care Providers:
experience true inter-professional learning,
Are able to crowd-source solutions to complex problems
Reduce stress/burnout through group support and validation that creates a “way forward” with complex patients
increase their willingness to care for a challenging patient population
Find patients are easier to manage in subsequent primary care visits

14. Challenges Innovative projects often not persuasive on their own
Scale and cost considerations
Measures are not necessarily well calibrated to the phenomenon
Systems need to be rethought and reconfigured